A living WHO guideline on drugs for covid-19

BMJ, The - Trang m3379
Arnav Agarwal1,2,3,4,5, Beverley J. Hunt6, Miriam Stegemann7, Bram Rochwerg1,2,4,5, François Lamontagne4,8,5, Reed Siemieniuk1,2,4,5, Thomas Agoritsas1,9,3,4,5, Lisa Askie4,10,5, Lyubov Lytvyn1,4,5, Yee‐Sin Leo11, Helen Macdonald4,12,5, Linan Zeng1,4,5, Ahmed Alhadyan13, Atiya Tasnim Muna14, Wagdy Amin15, André Ricardo Araújo da Silva16, Diptesh Aryal17, Fabián Alberto Jaimes Barragán18, Frédérique Jacquerioz Bausch19, Erlina Burhan20, Carolyn S. Calfee21, Maurizio Cecconi22, Binila Chacko23, Duncan Chanda24, Vu Quoc Dat25, An De Sutter26, Bin Du27, Stephen B. Freedman28, Heike Geduld29, Patrick O. Gee30, Muhammad Mohsin Haider31, Matthias Götte32, Nerina Harley33, Madiha Hashmi34, David S.C. Hui35, Mohamed Ismail36, Fyezah Jehan36, Sushil Kumar Kabra37, Seema Kanda38, Yae‐Jean Kim39, Niranjan Kissoon40, Sanjeev Krishna41, Krutika Kuppalli10, Arthur Kwizera42, Marta Lado Castro-Rial4,10,5, Thiago Lisboa43, Rakesh Lodha44, Imelda Mahaka45, Hela Manai46, Marc Mendelson47, Giovanni Battista Migliori48, G Miño49, Emmanuel Nsutebu50, Jessica Peter51, Jacobus Preller4,10,5, N. Pshenichnaya52, Nida Qadir53, Shalini Sri Ranganathan54, Pryanka Relan4,10,5, Jamie Rylance4,10,5, Saniya Sabzwari55, Rohit Sarin56, Manu Shankar‐Hari7, Mike Sharland57, Yinzhong Shen58, João Paulo Souza59, Ronald Swanstrom60, Tshokey Tshokey61, Sebastián Ugarte62, Timothy M. Uyeki63, Evangelina Vázquez Curiel64, Sridhar Venkatapuram65, Dubula Vuyiseka66, Ananda Wijewickrama67, Lien Tran4,62,5, Dena Zeraatkar1,4,5, Jessica Bartoszko1,4,5, Long Ge1,63,4,5, Romina Brignardello‐Petersen1,4,5, Andrew Owen64,4,5, Stefan Schandelmaier1,2,4,68,5, Janet Dı́az4,8,68,5, Letícia Kawano-Dourado65, Michael Jacobs66,68, Per Olav Vandvik67,3,4,68,5
1Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
2Department of Medicine, McMaster University, Hamilton, Ontario, Canada
3MAGIC Evidence Ecosystem Foundation, Oslo, Norway.
4Not Guideline Development Group member
5resource for methodology, systematic review, and content support
6King’s College London, St Thomas’ Hospital, London, UK
7National Institute of Tuberculosis and Respiratory Diseases, New Delhi, India
8Université de Sherbrooke, Centre de recherche due CHU de Sherbrooke, Quebec, Canada
9Division of General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
10World Health Organization, Geneva, Switzerland
11National Center for Infectious Diseases, Singapore
12The BMJ, London, UK
13Saudi Arabia
14Communicable Disease Center, Qatar
15Ministry of Health and Population, Cairo, Egypt
16Fluminense Federal University, Brazil
17Mediciti Hospital, Nepal
18Antioquia University Medellin, Colombia
19Geneva University Hospital, Switzerland
20Infection Division, Department of Pulmonology and Respiratory Medicine, Faculty of Medicine Universitas, Indonesia
21University of California, San Francisco, USA
22Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center, Italy
23Christian Medical College, Vellore, India
24Adult Infectious Disease Centre, University Teaching Hospital, Lusaka, Zambia
25Department of Infectious Diseases, Hanoi Medical University, Hanoi, Vietnam
26University of Gent, Belgium
27Peking Union Medical College Hospital, Beijing, China
28Department of Pediatrics, Cumming School of Medicine, University of Calgary, Canada
29Division of Emergency Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
30United States
31Ministry of Health, Afghanistan
32University of Alberta, Canada
33Royal Melbourne Hospital and Epworth Healthcare, Melbourne, Australia
34Ziauddin University, Karachi, Pakistan
35Stanley Ho Centre for Emerging Infectious Diseases, Chinese University of Hong Kong, China
36Indira Gandhi Memorial Hospital, Maldives
37Aga Khan University, Pakistan
38All India Institute of Medical Sciences, New Delhi, India
39McMaster University, Canada (alumnus)
40Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Republic of Korea
41Department of Paediatrics and Emergency Medicine, University of British Columbia, Vancouver, Canada
42St George's, University of London, UK
43Department of Anaesthesia and Critical Care, College of Health Sciences, Makerere University, Kampala, Uganda
44HCOR Hospital do Coracao, Sao Paulo, Brazil
45Department of Paediatrics, All India Institute of Medical Sciences, India
46Zimbabwe
47Emergency Medical Services, Faculty of Medicine, Tunis, Tunisia
48Groote Schuur Hospital, University of Cape Town, South Africa
49Clinical Scientific Institutes Maugeri, Italy
50Alcivar Hospital in Guayaquil, Ecuador
51Sheikh Shakhbout Medical City, Abu Dhabi
52Malaysia
53Central Research Institute of Epidemiology of Rospotrebnadzor, Moscow, Russia
54Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
55Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
56Aga Khan University, Karachi, Pakistan
57Guy’s and St Thomas’ NHS Foundation Trust, London, UK
58St. George's University Hospital, UK
59University of Colombo, Sri Lanka
60University of Sao Paulo, Brazil
61Charité - Universitätsmedizin, Berlin, Germany
62University of North Carolina USA
63JDW National Referral Hospital, Bhutan
64Faculty of Medicine Andres Bello University, Indisa Clinic, Santiago, Chile
65Influenza Division, U.S. Centers for Disease Control and Prevention, USA
66King's College, London, UK
67Department of Medicine, Lovisenberg Diaconal Hospital Trust, Oslo, Norway
68Co-senior author

Tóm tắt

Abstract Updates This is the fourteenth version (thirteenth update) of the living guideline, replacing earlier versions (available as data supplements). New recommendations will be published as updates to this guideline. Clinical question What is the role of drugs in the treatment of patients with covid-19? Context The evidence base for therapeutics for covid-19 is evolving with numerous randomised controlled trials (RCTs) recently completed and underway. Emerging SARS-CoV-2 variants and subvariants are changing the role of therapeutics. What is new? The guideline development group (GDG) defined 1.5% as a new threshold for an important reduction in risk of hospitalisation in patients with non-severe covid-19. Combined with updated baseline risk estimates, this resulted in stratification into patients at low, moderate, and high risk for hospitalisation. New recommendations were added for moderate risk of hospitalisation for nirmatrelvir/ritonavir, and for moderate and low risk of hospitalisation for molnupiravir and remdesivir. New pharmacokinetic evidence was included for nirmatrelvir/ritonavir and molnupiravir, supporting existing recommendations for patients at high risk of hospitalisation. The recommendation for ivermectin in patients with non-severe illness was updated in light of additional trial evidence which reduced the high degree of uncertainty informing previous guidance. A new recommendation was made against the antiviral agent VV116 for patients with non-severe and with severe or critical illness outside of randomised clinical trials based on one RCT comparing the drug with nirmatrelvir/ritonavir. The structure of the guideline publication has also been changed; recommendations are now ordered by severity of covid-19. About this guideline This living guideline from the World Health Organization (WHO) incorporates new evidence to dynamically update recommendations for covid-19 therapeutics. The GDG typically evaluates a therapy when the WHO judges sufficient evidence is available to make a recommendation. While the GDG takes an individual patient perspective in making recommendations, it also considers resource implications, acceptability, feasibility, equity, and human rights. This guideline was developed according to standards and methods for trustworthy guidelines, making use of an innovative process to achieve efficiency in dynamic updating of recommendations. The methods are aligned with the WHO Handbook for Guideline Development and according to a pre-approved protocol (planning proposal) by the Guideline Review Committee (GRC). A box at the end of the article outlines key methodological aspects of the guideline process. MAGIC Evidence Ecosystem Foundation provides methodological support, including the coordination of living systematic reviews with network meta-analyses to inform the recommendations. The full version of the guideline is available online in MAGICapp and in PDF on the WHO website, with a summary version here in The BMJ . These formats should facilitate adaptation, which is strongly encouraged by WHO to contextualise recommendations in a healthcare system to maximise impact. Future recommendations Recommendations on anticoagulation are planned for the next update to this guideline. Updated data regarding systemic corticosteroids, azithromycin, favipiravir and umefenovir for non-severe illness, and convalescent plasma and statin therapy for severe or critical illness, are planned for review in upcoming guideline iterations.

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